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Simon J, Hrenkó Á, Kerkovits NM, Nagy K, Vértes M, Balogh H, Nagy N, Munkácsi T, Emrich T, Varga-Szemes A, Boussoussou M, Vattay B, Vecsey-Nagy M, Kolossváry M, Szilveszter B, Merkely B, Maurovich-Horvat P. Photon-counting detector CT reduces the rate of referrals to invasive coronary angiography as compared to CT with whole heart coverage energy-integrating detector. J Cardiovasc Comput Tomogr 2024; 18:69-74. [PMID: 38097408 DOI: 10.1016/j.jcct.2023.11.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/19/2023] [Accepted: 11/24/2023] [Indexed: 02/26/2024]
Abstract
BACKGROUND We sought to compare the degree of maximal stenosis and the rate of invasive coronary angiography (ICA) recommendations in patients who underwent coronary CT angiography (CCTA) with photon-counting detector CT (PCD-CT) versus those who underwent CCTA with whole heart coverage energy-integrating detector CT (EID-CT). METHODS In our retrospective single-center study, we included consecutive patients with suspected CAD who underwent CCTA performed with either PCD-CT or a 280-slice EID-CT. The degree of coronary stenosis was classified as no CAD, minimal (1-24 %), mild (25-49 %), moderate (50-69 %), severe stenosis (70-99 %), or occlusion. RESULTS A total of 812 consecutive patients were included in the analysis, 401 patients scanned with EID-CT and 411 patients with PCD-CT (mean age: 58.4 ± 12.4 years, 45.4 % female). Despite the higher total coronary artery calcium score (CACS) in the PCD-CT group (10 [interquartile range (IQR) = 0-152.8] vs 1 [IQR = 0-94], p < 0.001), obstructive CAD was more frequently reported in the EID-CT vs PCD-CT group (no CAD: 28.7 % vs 26.0 %, minimal: 23.2 % vs 30.9 %, mild: 19.7 % vs 23.4 %, moderate: 14.5 % vs 9.7 %, severe: 11.5 % vs 8.5 % and occlusion: 2.5 % vs 1.5 %, respectively, p = 0.025). EID-CT was independently associated with downstream ICA (OR = 2.76 [95%CI = 1.58-4.97] p < 0.001) in the overall patient population, in patients with CACS<400 (OR = 2.18 [95%CI = 1.13-4.39] p = 0.024) and in patients with CACS≥400 (OR = 3.83 [95%CI = 1.42-11.05] p = 0.010). CONCLUSION In patients who underwent CCTA with PCD-CT the number of subsequent ICAs was lower as compared to patients who were scanned with EID-CT. This difference was greater in patients with extensive coronary calcification.
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Affiliation(s)
- Judit Simon
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Áron Hrenkó
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Nóra Melinda Kerkovits
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Kristóf Nagy
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Miklós Vértes
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Hanna Balogh
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Norbert Nagy
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Tamás Munkácsi
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Tilman Emrich
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | | | - Borbála Vattay
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Milán Vecsey-Nagy
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Márton Kolossváry
- Gottsegen National Cardiovascular Center, Budapest, Hungary; Physiological Controls Research Center, University Research and Innovation Center, Óbuda University, Hungary
| | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary.
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Hitter R, Orlev A, Amsalem I, Levi N, Wolak T, Farkash R, Bogot N, Glikson M, Wolak A. The Added Value of a High CT Coronary Artery Calcium Score in the Management of Patients Presenting with Acute Chest Pain vs. Stable Chest Pain. J Cardiovasc Dev Dis 2022; 9:jcdd9110390. [PMID: 36421925 PMCID: PMC9694127 DOI: 10.3390/jcdd9110390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Contrast computerized tomography (CT) scan is occasionally aborted due to a high coronary artery calcium score (CACS). For the same CACS in our clinical practice, we observed a higher occurrence of severe coronary artery disease (CAD) in patients with acute chest pain (ACP) compared to patients with stable chest pain (SCP). Since it is known that ACP differs in many ways from SCP, the aim of this study was to compare the predictive value of a high CACS for the diagnosis of severe CAD between ACP and SCP patients. Methods: This single center observational retrospective study included consecutive patients who underwent cardiac CT for chest pain and were found to have a CACS of >200 Agatston units. Patients were divided into two groups, ACP and SCP. Severe CAD was defined as ≥70% stenosis on coronary CT angiography or invasive coronary angiography. Baseline characteristics and final diagnosis of severe CAD were compared. Results: The cohort included 220 patients, 106 with ACP and 114 with SCP. ACP patients had higher severe CAD rates (60.4% vs. 36.8%; p < 0.001). On multivariate analysis including cardiac risk factors, CACS > 400 au (OR = 2.34 95% CI [1.32−4.15]; p = 0.004) and ACP (OR = 2.54 95% CI [1.45−4.45]; p = 0.001) were independent predictors of severe CAD. The addition of the clinical setting of ACP added significant incremental predictive value for severe stenosis. Conclusion: A high CACS is more associated with severe CAD in patients presenting with ACP than SCP. The findings suggest that the CACS could impact the management of patients during the scan.
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Affiliation(s)
- Rafael Hitter
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Amir Orlev
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Itshak Amsalem
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Nir Levi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Talya Wolak
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Rivka Farkash
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Naama Bogot
- Department of Radiology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Arik Wolak
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
- Correspondence: ; Tel.: +972-2-6555955; Fax: +972-2-6555437
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Agha AM, Pacor J, Grandhi GR, Mszar R, Khan SU, Parikh R, Agrawal T, Burt J, Blankstein R, Blaha MJ, Shaw LJ, Al-Mallah MH, Brackett A, Cainzos-Achirica M, Miller EJ, Nasir K. The Prognostic Value of CAC Zero Among Individuals Presenting With Chest Pain: A Meta-Analysis. JACC Cardiovasc Imaging 2022; 15:1745-1757. [PMID: 36202453 DOI: 10.1016/j.jcmg.2022.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 03/17/2022] [Accepted: 03/31/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is little consensus on whether absence of coronary artery calcium (CAC) can identify patients with chest pain (CP) who can safely avoid additional downstream testing. OBJECTIVES The purpose of this study was to conduct a systematic review and meta-analysis investigating the utility of CAC assessment for ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP, at low-to-intermediate risk of obstructive CAD undergoing coronary computed tomography angiography (CTA). METHODS The authors searched online databases for studies published between 2005 and 2021 examining the relationship between CAC and obstructive CAD (≥50% coronary luminal narrowing) on coronary CTA among patients with stable and acute CP. RESULTS In this review, the authors included 19 papers comprising 79,903 patients with stable CP and 13 papers including 12,376 patients with acute CP undergoing simultaneous CAC and coronary CTA assessment. Overall, 45% (95% CI: 40%-50%) of patients with stable CP and 58% (95% CI: 50%-66%) of patients with acute CP had CAC = 0. The negative predictive values for CAC = 0 ruling out obstructive CAD were 97% (95% CI: 96%-98%) and 98% (95% CI: 96%-99%) among patients with stable and acute CP, respectively. Additionally, the prevalence of nonobstructive CAD among those with CAC = 0 was 13% (95% CI: 10%-16%) among those with stable CP and 9% (95% CI: 5%-13%) among those with acute CP. A CAC score of zero predicted a low incidence of major adverse cardiac events among patients with stable CP (0.5% annual event rate) and acute CP (0.8% overall event rate). CONCLUSIONS Among over 92,000 patients with stable or acute CP, the absence of CAC was associated with a very low prevalence of obstructive CAD, a low prevalence of nonobstructive CAD, and a low annualized risk of major adverse cardiac events. These findings support the role of CAC = 0 in a value-based health care delivery model as a "gatekeeper" for more advanced imaging among patients presenting with CP.
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Affiliation(s)
- Ali M Agha
- Baylor College of Medicine, Houston, Texas, USA
| | - Justin Pacor
- Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | - Reed Mszar
- Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Safi U Khan
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Roosha Parikh
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Tanushree Agrawal
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Jeremy Burt
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | | | | | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Khurram Nasir
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
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Koopman MY, Reijnders JJW, Willemsen RTA, van Bruggen R, Doggen CJM, Kietselaer B, Oude Wolcherink MJ, van Ooijen PMA, Gratama JWC, Braam R, Oudkerk M, van der Harst P, Dinant GJ, Vliegenthart R. Coronary calcium scoring as first-line test to detect and exclude coronary artery disease in patients presenting to the general practitioner with stable chest pain: protocol of the cluster-randomised CONCRETE trial. BMJ Open 2022; 12:e055123. [PMID: 35440450 PMCID: PMC9020291 DOI: 10.1136/bmjopen-2021-055123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Identifying and excluding coronary artery disease (CAD) in patients with atypical angina pectoris (AP) and non-specific thoracic complaints is a challenge for general practitioners (GPs). A diagnostic and prognostic tool could help GPs in determining the likelihood of CAD and guide patient management. Studies in outpatient settings have shown that the CT-based coronary calcium score (CCS) has high accuracy for diagnosis and exclusion of CAD. However, the CT CCS test has not been tested in a primary care setting. In the COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GPs patients with stable chest pain (CONCRETE) study, the impact of direct access of GPs to CT CCS will be investigated. We hypothesise that this will allow for early diagnosis of CAD and treatment, more efficient referral to the cardiologist and a reduction of healthcare-related costs. METHODS AND ANALYSIS CONCRETE is a pragmatic multicentre trial with a cluster randomised design, in which direct GP access to the CT CCS test is compared with standard of care. In both arms, at least 40 GP offices, and circa 800 patients with atypical AP and non-specific thoracic complaints will be included. To determine the increase in detection and treatment rate of CAD in GP offices, the CVRM registration rate is derived from the GPs electronic registration system. Individual patients' data regarding cardiovascular risk factors, expressed chest pain complaints, quality of life, downstream testing and CAD diagnosis will be collected through questionnaires and the electronic GP dossier. ETHICS AND DISSEMINATION CONCRETE has been approved by the Medical Ethical Committee of the University Medical Center of Groningen. TRIAL REGISTRATION NUMBER NTR 7475; Pre-results.
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Affiliation(s)
- Moniek Y Koopman
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jorn J W Reijnders
- Department of Cardiology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Robert T A Willemsen
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Rykel van Bruggen
- Multicenter General Practitioners Organisation 'HuisartsenOrganisatie Oost-Gelderland', Apeldoorn, The Netherlands
| | - Carine J M Doggen
- Department of Health Technology & Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Bas Kietselaer
- Department of Cardiology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Martijn J Oude Wolcherink
- Department of Health Technology & Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Peter M A van Ooijen
- Department of Data Science Center in Health, University of Groniningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Richard Braam
- Department of Cardiology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Matthijs Oudkerk
- Department of Medical Science, University of Groningen, Groningen, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, Division of Heart and Lungs, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Rozemarijn Vliegenthart
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Lopes PM, Albuquerque F, Freitas P, Rocha BM, Cunha GJ, Santos AC, Abecasis J, Guerreiro S, Saraiva C, Mendes M, Ferreira AM. The updated pre-test probability model of the 2019 ESC guidelines improves prediction of obstructive coronary artery disease. Rev Port Cardiol 2022; 41:445-452. [DOI: 10.1016/j.repc.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 10/18/2022] Open
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6
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Koopman MY, Willemsen RTA, van der Harst P, van Bruggen R, Gratama JWC, Braam R, van Ooijen PMA, Doggen CJM, Dinant GJ, Kietselaer B, Vliegenthart R. The Diagnostic and Prognostic Value of Coronary Calcium Scoring in Stable Chest Pain Patients: A Narrative Review. ROFO-FORTSCHR RONTG 2022; 194:257-265. [PMID: 35081649 PMCID: PMC8837467 DOI: 10.1055/a-1662-5711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background
Non-contrast computed tomography (CT) scanning allows for reliable coronary calcium score (CCS) calculation at a low radiation dose and has been well established as marker to assess the future risk of coronary artery disease (CAD) events in asymptomatic individuals. However, the diagnostic and prognostic value in symptomatic patients remains a matter of debate. This narrative review focuses on the available evidence for CCS in patients with stable chest pain complaints.
Method
PubMed, Embase, and Web of Science were searched for literature using search terms related to three overarching categories: CT, symptomatic chest pain patients, and coronary calcium. The search resulted in 42 articles fulfilling the inclusion and exclusion criteria: 27 articles (n = 38 137 patients) focused on diagnostic value and 23 articles (n = 44 683 patients) on prognostic value of CCS. Of these, 10 articles (n = 21 208 patients) focused on both the diagnostic and prognostic value of CCS.
Results
Between 22 and 10 037 patients were included in the studies on the diagnostic and prognostic value of CCS, including 43 % and 51 % patients with CCS 0. The most evidence is available for patients with a low and intermediate pre-test probability (PTP) of CAD. Overall, the prevalence of obstructive CAD (OCAD, defined as a luminal stenosis of ≥ 50 % in any of the coronary arteries) as determined with CT coronary angiography in CCS 0 patients, was 4.4 % (n = 703/16 074) with a range of 0–26 % in individual studies. The event rate for major adverse cardiac events (MACE) ranged from 0 % to 2.1 % during a follow-up of 1.6 to 6.8 years, resulting in a high negative predictive value for MACE between 98 % and 100 % in CCS 0 patients. At increasing CCS, the OCAD probability and MACE risk increased. OCAD was present in 58.3 % (n = 617/1058) of CCS > 400 patients with percentages ranging from 20 % to 94 % and MACE occurred in 16.7 % (n = 175/1048) of these patients with percentages ranging from 6.9 % to 50 %.
Conclusion
Accumulating evidence shows that OCAD is unlikely and the MACE risk is very low in symptomatic patients with CCS 0, especially in those with low and intermediate PTPs. This suggests a role of CCS as a gatekeeper for additional diagnostic testing. Increasing CCS is related to an increasing probability of OCAD and risk of cardiac events. Additional research is needed to assess the value of CCS in women and patient management in a primary healthcare setting.
Key Points:
Citation Format
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Affiliation(s)
| | | | - Pim van der Harst
- Cardiology, University Medical Centre Utrecht Department of Cardiology, Utrecht, Netherlands.,Division Heart and Lungs, University Medical Centre Groningen, Netherlands
| | - Rykel van Bruggen
- Primary Health Care, Multicenter General Practitioners Organisation "HuisartsenOrganisatie Oost-Gelderland", Apeldoorn, Netherlands
| | | | | | - Peter M A van Ooijen
- Data Science Center in Health, University Medical Centre Groningen, Netherlands.,Radiation Oncology, University Medical Centre Groningen, Netherlands
| | - Carine J M Doggen
- Health Technology & Services Research, Techmed Centre, University of Twente, Enschede, Netherlands
| | | | - Bas Kietselaer
- Cardiology, Zuyderland Medical Centre Sittard-Geleen, Netherlands
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Grundy SM, Stone NJ. Coronary Artery Calcium: Where Do We Stand After Over 3 Decades? Am J Med 2021; 134:1091-1095. [PMID: 34019857 DOI: 10.1016/j.amjmed.2021.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/19/2022]
Abstract
In 2018, cardiovascular society cholesterol guidelines recommended the use of coronary artery calcium to guide statin therapy in patients 40-79 years of age who are at intermediate risk by multiple risk factor equations (ie, estimated 10-year risk for atherosclerotic disease of 7.5%-19.9% but in whom statin benefit is uncertain). Many such patients have no coronary calcium and remain at <5% risk over the next decade; hence, statin therapy can be delayed until a repeat calcium scan is conducted. Exceptions include patients with severe hypercholesterolemia, diabetes, and a strong family history of atherosclerotic disease. If coronary calcium equals 1-99 Agatston units, the 10-year risk is borderline (5% to <7.5%) and statin therapy is optional pending a repeat scan. If coronary calcium equals 100-299 Agatston units, the patient is clearly statin eligible (7.5% to <20% 10-year risk). And finally, if coronary calcium is ≥300 Agatston units, a patient is at high risk and is a candidate for high-intensity statins. Risk factor analysis combined judiciously with coronary calcium scanning offers the strongest evidence-based approach to use of statins in primary prevention.
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Affiliation(s)
- Scott M Grundy
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
| | - Neil J Stone
- Northwestern University Feinberg School of Medicine, Chicago, Ill
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Trpkov C, Savtchenko A, Liang Z, Feng P, Southern DA, Wilton SB, James MT, Feil E, Mylonas I, Miller RJH. Visually estimated coronary artery calcium score improves SPECT-MPI risk stratification. IJC HEART & VASCULATURE 2021; 35:100827. [PMID: 34195354 PMCID: PMC8233133 DOI: 10.1016/j.ijcha.2021.100827] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/30/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022]
Abstract
Aims Computed tomographic attenuation correction (CTAC) scans for single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) may reveal coronary artery calcification. The independent prognostic value of a visually estimated coronary artery calcium score (VECACS) from these low-dose, non-gated scans is not established. Methods & Results VECACS was evaluated in 4,720 patients undergoing SPECT-MPI with CTAC using a 4-point scale. Major adverse cardiac events (MACE) were defined as all-cause mortality, acute coronary syndrome, or revascularization > 90 days after SPECT-MPI. Independent associations with MACE were determined with multivariable Cox proportional hazards analyses adjusted for age, sex, past medical history, perfusion findings, and left ventricular ejection fraction. During a median follow up of 2.9 years (interquartile range 1.8 - 4.2), 494 (10.5%) patients experienced MACE. Compared to absent VECACS, patients with increased VECACS were more likely to experience MACE (all log-rank p < 0.001), and findings were similar when stratified by normal or abnormal perfusion. Multivariable analysis showed an increased MACE risk associated with VECACS categories of equivocal (adjusted hazard ratio [HR] 2.54, 95% CI 1.45-4.45, p = 0.001), present (adjusted HR 2.44, 95% CI 1.74-3.42, p < 0.001) and extensive (adjusted HR 3.47, 95% CI 2.41-5.00, p < 0.001) compared to absent. Addition of VECACS to the multivariable model improved risk classification (continuous net reclassification index 0.207, 95% CI 0.131 - 0.310). Conclusion VECACS was an independent predictor of MACE in this large SPECT-MPI patient cohort. VECACS from CTAC can be used to improve risk stratification with SPECT-MPI without additional radiation.
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Affiliation(s)
- Cvetan Trpkov
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Alexei Savtchenko
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Zhiying Liang
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Patrick Feng
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Danielle A Southern
- Department of Medicine, Department of Community Health Sciences, O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen B Wilton
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Matthew T James
- Department of Medicine, Department of Community Health Sciences, O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Erin Feil
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Ilias Mylonas
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Robert J H Miller
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, AB, Canada
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9
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Huang W, Lim LMH, Aurangzeb AS, Wong CJ, Koh NSY, Huang Z, Teo HK, Chua TSJ, Tan SY. Performance of the coronary calcium score in an outpatient chest pain clinic and strategies for risk stratification. Clin Cardiol 2021; 44:267-275. [PMID: 33434373 PMCID: PMC7852173 DOI: 10.1002/clc.23539] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 11/23/2022] Open
Abstract
Background Coronary artery calcium score (CAC) is an objective marker of atherosclerosis. The primary aim is to assess CAC as a risk classifier in stable coronary artery disease (CAD). Hypothesis CAC improves CAD risk prediction, compared to conventional risk scoring, even in the absence of cardiovascular risk factor inputs. Methods Outpatients presenting to a cardiology clinic (n = 3518) were divided into two cohorts: derivation (n = 2344 patients) and validation (n = 1174 patients). Adding logarithmic transformation of CAC, we built two logistic regression models: Model 1 with chest pain history and risk factors and Model 2 including chest pain history only without risk factors simulating patients with undiagnosed comorbidities. The CAD I Consortium Score (CCS) was the conventional reference risk score used. The primary outcome was the presence of coronary artery disease defined as any epicardial artery stenosis≥50% on CT coronary angiogram. Results Area under curve (AUC) of CCS in our validation cohort was 0.80. The AUC of Models 1 and 2 were significantly improved at 0.88 (95%CI 0.86–0.91) and 0.87 (95%CI 0.84–0.90), respectively. Integrated discriminant improvement was >15% for both models. At a pre‐specified cut‐off of ≤10% for excluding coronary artery disease, the sensitivity and specificity were 89.3% and 74.7% for Model 1, and 88.1% and 71.8% for Model 2. Conclusion CAC helps improve risk classification in patients with chest pain, even in the absence of prior risk factor screening.
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Affiliation(s)
- Weiting Huang
- Cardiology, National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Leon Ming Hsien Lim
- Yong Loo Lin School of Medicine, 10 Medical Drive, Singapore, 117597, Singapore
| | | | - Cheney Jianlin Wong
- Cardiology, National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Natalie Si Ya Koh
- Cardiology, National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Zijuan Huang
- Cardiology, National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Hooi Khee Teo
- Cardiology, National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | | | - Swee Yaw Tan
- Cardiology, National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
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10
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Simon J, Száraz L, Szilveszter B, Panajotu A, Jermendy Á, Bartykowszki A, Boussoussou M, Vattay B, Drobni ZD, Merkely B, Maurovich-Horvat P, Kolossváry M. Calcium scoring: a personalized probability assessment predicts the need for additional or alternative testing to coronary CT angiography. Eur Radiol 2020; 30:5499-5506. [PMID: 32405749 PMCID: PMC7476992 DOI: 10.1007/s00330-020-06921-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/23/2020] [Accepted: 04/28/2020] [Indexed: 01/07/2023]
Abstract
Objective To assess whether anthropometrics, clinical risk factors, and coronary artery calcium score (CACS) can predict the need of further testing after coronary CT angiography (CTA) due to non-diagnostic image quality and/or the presence of significant stenosis. Methods Consecutive patients who underwent coronary CTA due to suspected coronary artery disease (CAD) were included in our retrospective analysis. We used multivariate logistic regression and receiver operating characteristics analysis containing anthropometric factors: body mass index, heart rate, and rhythm irregularity (model 1); and parameters used for pre-test likelihood estimation: age, sex, and type of angina (model 2); and also added total calcium score (model 3) to predict downstream testing. Results We analyzed 4120 (45.7% female, 57.9 ± 12.1 years) patients. Model 3 significantly outperformed models 1 and 2 (area under the curve, 0.84 [95% CI 0.83–0.86] vs. 0.56 [95% CI 0.54–0.58] and 0.72 [95% CI 0.70–0.74], p < 0.001). For patients with sinus rhythm of 50 bpm, in case of non-specific angina, CACS above 435, 756, and 944; in atypical angina CACS above 381, 702, and 890; and in typical angina CACS above 316, 636, and 824 correspond to 50%, 80%, and 90% probability of further testing, respectively. However, higher heart rates and arrhythmias significantly decrease these cutoffs (p < 0.001). Conclusion CACS significantly increases the ability to identify patients in whom deferral from coronary CTA may be advised as CTA does not lead to a final decision regarding CAD management. Our results provide individualized cutoff values for given probabilities of the need of additional testing, which may facilitate personalized decision-making to perform or defer coronary CTA. Key Points • Anthropometric parameters on their own are insufficient predictors of downstream testing. Adding parameters of the Diamond and Forrester pre-test likelihood test significantly increases the power of prediction. • Total CACS is the most important independent predictor to identify patients in whom coronary CTA may not be recommended as CTA does not lead to a final decision regarding CAD management. • We determined specific CACS cutoff values based on the probability of downstream testing by angina-, arrhythmia-, and heart rate–based groups of patients to help individualize patient management. Electronic supplementary material The online version of this article (10.1007/s00330-020-06921-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Judit Simon
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Lili Száraz
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Alexisz Panajotu
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ádám Jermendy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Andrea Bartykowszki
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Melinda Boussoussou
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Borbála Vattay
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsófia Dóra Drobni
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.,Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
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11
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Batlle JC, Kirsch J, Bolen MA, Bandettini WP, Brown RKJ, Francois CJ, Galizia MS, Hanneman K, Inacio JR, Johnson TV, Khosa F, Krishnamurthy R, Rajiah P, Singh SP, Tomaszewski CA, Villines TC, Wann S, Young PM, Zimmerman SL, Abbara S. ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome. J Am Coll Radiol 2020; 17:S55-S69. [PMID: 32370978 DOI: 10.1016/j.jacr.2020.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 12/17/2022]
Abstract
Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Juan C Batlle
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida.
| | - Jacobo Kirsch
- Panel Chair, Cleveland Clinic Florida, Weston, Florida
| | | | - W Patricia Bandettini
- National Institutes of Health, Bethesda, Maryland; Society for Cardiovascular Magnetic Resonance
| | | | | | | | - Kate Hanneman
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joao R Inacio
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas V Johnson
- Sanger Heart and Vascular Institute, Charlotte, North Carolina; Cardiology Expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear Cardiology Expert
| | | | | | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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12
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Moradi M, Mahdavi MMB, Nogourani MK. The Relation of Calcium Volume Score and Stenosis of Carotid Artery. J Stroke Cerebrovasc Dis 2020; 29:104493. [PMID: 31734123 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 10/13/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the value of extracranial carotid artery calcium score in predicting severity of carotid arterial stenosis. MATERIAL AND METHODS 200 patients who had indication of contrast neck multi detector computed tomography were included. Calcium volume score of each calcified plaque (density more than 130 HU) was determined by multiplying area of calcified plaque in slice increment and presented as cubic centimeter (cc). Calcium score of each side (right or left) and each patient were determined. Severity of carotid stenosis in axial images was estimated and categorized. Statistical analysis was performed. RESULTS 87 cases were female with mean age of 58.90 ± 10.67 and 113 cases were male with mean age of 59.61 ± 11.89 years old. The mean of volume score for all evaluated 800 vessels was .079 ± .046 cc. There was no significant difference between calcium score of right and left side (P value = .16). The mean "patient score" was .080 ± .049 cc (range: 0-.15 cc).Nine patients had volume score of 0 and all of them had no evidence of luminal stenosis. Significant increase in severity of stenosis was seen with increase in "patient score".(P value < .001, r = .875).According to receiver operating characteristic analysis, "patient score" of .09 cc with sensitivity of 97% and "patient score" of .12 cc with sensitivity of 95% can predict 50% and 70% stenosis, respectively. CONCLUSIONS Promising role of calcium score for predicting severity of carotid stenosis could be considered.
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Affiliation(s)
- Maryam Moradi
- Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| | | | - Mehdi Karami Nogourani
- Department of Radiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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13
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Jeevarethinam A, Venuraju S, Dumo A, Ruano S, Mehta VS, Rosenthal M, Nair D, Cohen M, Darko D, Lahiri A, Rakhit R. Relationship between carotid atherosclerosis and coronary artery calcification in asymptomatic diabetic patients: A prospective multicenter study. Clin Cardiol 2017; 40:752-758. [PMID: 28543093 DOI: 10.1002/clc.22727] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 04/25/2017] [Accepted: 04/28/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The value of screening sub-clinical atherosclerosis in asymptomatic patients with type 2 diabetes mellitus (T2DM) remains controversial. HYPOTHESIS An integrated model incorporating carotid intima-media thickness (CIMT) and carotid plaque with traditional risk factors can be used to predict prevalence and severity of coronary artery calcification in asymptomatic T2DM patients. METHODS A cohort of 262 asymptomatic T2DM patients were prospectively studied with carotid ultrasound to evaluate CIMT and carotid plaque and also a computed tomography coronary artery calcium (CT-CAC) scan. RESULTS Carotid plaque was detected in 124 (47%) patients and mean CIMT was 0.75±0.14 mm. Two hundred (76%) patients had a CAC score >0, of whom 57 (22%) had severe coronary atherosclerosis (>400 Au). In this group, carotid plaque was present in 40 (70%) patients (p<0.001). Univariable analysis revealed significant associations between non-zero CAC score and age (p<0.001), hypertension (p=0.01), gender (p=0.003) and duration of diabetes (p=0.004). Carotid plaque and mean CIMT were also significantly associated with non-zero CAC score (odds ratios [95% CI], 3.12 [1.66 -5.85] and 2.98 [0.24 -7.17], respectively). After adjusting for traditional risk factors, carotid plaque continued to be predictive of non-zero CAC score (2.59 [1.17 -5.74]) and CIMT was borderline significant (p=0.05). When analysed with binary logistical regression, the prevalence of carotid plaque significantly predicted severe CAC burden (CAC >400 Au; 3.26 [2.05 -5.19]). Upper CIMT quartiles showed a similar association (2.55 [1.33 -4.87]). CONCLUSION Carotid plaque is more predictive of underlying silent coronary atherosclerosis prevalence, severity and extent in asymptomatic T2DM patients.
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Affiliation(s)
- Anand Jeevarethinam
- Cardiac Imaging and Research Centre, Wellington Hospital, London, United Kingdom.,Institute of Cardiovascular Sciences, University College London, United Kingdom
| | - Shreenidhi Venuraju
- Cardiac Imaging and Research Centre, Wellington Hospital, London, United Kingdom.,Institute of Cardiovascular Sciences, University College London, United Kingdom
| | - Alain Dumo
- British Cardiac Research Trust, Cardiac Imaging and Research Centre, Wellington Hospital, London, United Kingdom
| | - Sherezade Ruano
- British Cardiac Research Trust, Cardiac Imaging and Research Centre, Wellington Hospital, London, United Kingdom
| | - Vishal S Mehta
- Royal Free and UCL Medical School, London, United Kingdom
| | - Miranda Rosenthal
- Department of Diabetes and Endocrinology, Royal Free Hospital, London, United Kingdom
| | - Devaki Nair
- Department of Clinical Biochemistry, Royal Free Hospital, London, United Kingdom
| | - Mark Cohen
- Department of Diabetes and Endocrinology, Barnet Hospital, London, United Kingdom
| | - Daniel Darko
- The Jeffrey Kelson Centre for Diabetes and Endocrinology, Central Middlesex Hospital, London, United Kingdom
| | - Avijit Lahiri
- Cardiac Imaging and Research Centre, Wellington Hospital, London, United Kingdom.,Imperial College of Medicine, Imperial College London, UK.,Healthcare Science, Middlesex University, London, UK
| | - Roby Rakhit
- Department of Cardiology, Royal Free Hospital, London, United Kingdom
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14
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Akers SR, Panchal V, Ho VB, Beache GM, Brown RK, Ghoshhajra BB, Greenberg SB, Hsu JY, Kicska GA, Min JK, Stillman AE, Stojanovska J, Abbara S, Jacobs JE. ACR Appropriateness Criteria ® Chronic Chest Pain—High Probability of Coronary Artery Disease. J Am Coll Radiol 2017; 14:S71-S80. [DOI: 10.1016/j.jacr.2017.01.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
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15
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Moradi M, Nouri S, Nourozi A, Golbidi D. Prognostic Value of Coronary Artery Calcium Score for Determination of Presence and Severity of Coronary Artery Disease. Pol J Radiol 2017; 82:165-169. [PMID: 28392854 PMCID: PMC5378275 DOI: 10.12659/pjr.900643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 08/10/2016] [Indexed: 11/13/2022] Open
Abstract
Background There are controversies regarding the usefulness of coronary artery calcium score (CACS) for predicting coronary artery stenosis. The aim of this study was to determine the prognostic value of CACS for determining the presence and severity of coronary artery disease (CAD) in patients with sign and symptoms of the disease. Material/Methods In this cross-sectional study, 748 consecutive patients with suspected CAD, referred for coronary computed tomography angiography (CCTA), were enrolled. The mean CACS was compared between patients with different severities of coronary artery stenosis. The association between CACS and different CAD risk factors was determined as well. Different cutoff points of CACS for discriminating between different levels of coronary artery stenosis was determined using receiver operating characteristic (ROC) curves. Results The mean CACS was significantly different between different levels of coronary artery stenosis (P<0.001) and there was a significant positive association between the severity of CAD and CACS (P<0.001,r=0.781). ROC curve analysis indicated that the optimal cutoff point for discriminating between CAD (presence of stenosis) and the non-stenosis condition was 5.35 with 88.6% sensitivity and 86.2% specificity. Area under the curve for different levels of coronary artery stenosis did not have sufficient sensitivity and specificity for discriminating between different levels of CAD severity (<70%). Conclusions The study demonstrated that there is a significant association between CACS and the presence as well as the severity of CAD. CACS could have an appropriate prognostic value for the determination of coronary artery stenosis but not for discriminating between different severities of stenoses.
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Affiliation(s)
- Maryam Moradi
- Department of Radiology, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Nouri
- Department of Radiology, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Nourozi
- Department of Radiology, Sina Hospital, Isfahan, Iran
| | - Danial Golbidi
- Department of Radiology, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
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16
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Chaikriangkrai K, Palamaner Subash Shantha G, Jhun HY, Ungprasert P, Sigurdsson G, Nabi F, Mahmarian JJ, Chang SM. Prognostic Value of Coronary Artery Calcium Score in Acute Chest Pain Patients Without Known Coronary Artery Disease: Systematic Review and Meta-analysis. Ann Emerg Med 2016; 68:659-670. [DOI: 10.1016/j.annemergmed.2016.07.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/24/2016] [Accepted: 07/13/2016] [Indexed: 01/07/2023]
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17
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Influence of the coronary calcium score on the ability to rule out coronary artery stenoses by coronary CT angiography in patients with suspected coronary artery disease. J Cardiovasc Comput Tomogr 2016; 10:343-50. [DOI: 10.1016/j.jcct.2016.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 11/23/2022]
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18
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Ferreira AM, Marques H, Tralhão A, Santos MB, Santos AR, Cardoso G, Dores H, Carvalho MS, Madeira S, Machado FP, Cardim N, de Araújo Gonçalves P. Pre-test probability of obstructive coronary stenosis in patients undergoing coronary CT angiography: Comparative performance of the modified diamond-Forrester algorithm versus methods incorporating cardiovascular risk factors. Int J Cardiol 2016; 222:346-351. [PMID: 27500762 DOI: 10.1016/j.ijcard.2016.07.180] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/27/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Current guidelines recommend the use of the Modified Diamond-Forrester (MDF) method to assess the pre-test likelihood of obstructive coronary artery disease (CAD). We aimed to compare the performance of the MDF method with two contemporary algorithms derived from multicenter trials that additionally incorporate cardiovascular risk factors: the calculator-based 'CAD Consortium 2' method, and the integer-based CONFIRM score. METHODS We assessed 1069 consecutive patients without known CAD undergoing coronary CT angiography (CCTA) for stable chest pain. Obstructive CAD was defined as the presence of coronary stenosis ≥50% on 64-slice dual-source CT. The three methods were assessed for calibration, discrimination, net reclassification, and changes in proposed downstream testing based upon calculated pre-test likelihoods. RESULTS The observed prevalence of obstructive CAD was 13.8% (n=147). Overestimations of the likelihood of obstructive CAD were 140.1%, 9.8%, and 18.8%, respectively, for the MDF, CAD Consortium 2 and CONFIRM methods. The CAD Consortium 2 showed greater discriminative power than the MDF method, with a C-statistic of 0.73 vs. 0.70 (p<0.001), while the CONFIRM score did not (C-statistic 0.71, p=0.492). Reclassification of pre-test likelihood using the 'CAD Consortium 2' or CONFIRM scores resulted in a net reclassification improvement of 0.19 and 0.18, respectively, which would change the diagnostic strategy in approximately half of the patients. CONCLUSIONS Newer risk factor-encompassing models allow for a more precise estimation of pre-test probabilities of obstructive CAD than the guideline-recommended MDF method. Adoption of these scores may improve disease prediction and change the diagnostic pathway in a significant proportion of patients.
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Affiliation(s)
- António Miguel Ferreira
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal.
| | - Hugo Marques
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal
| | - António Tralhão
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal
| | - Miguel Borges Santos
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal
| | - Ana Rita Santos
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Hospital Distrital de Évora, Largo Senhor da Pobreza, Évora, Portugal
| | - Gonçalo Cardoso
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal
| | - Hélder Dores
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal
| | - Maria Salomé Carvalho
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal
| | - Sérgio Madeira
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal
| | | | - Nuno Cardim
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal
| | - Pedro de Araújo Gonçalves
- Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal; CEDOC, Chronic Diseases Research Center, FCM-NOVA, Lisbon, Portugal
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19
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Kim HY, Choi JH. How to Utilize Coronary Computed Tomography Angiography in the Treatment of Coronary Artery Disease. J Cardiovasc Ultrasound 2015; 23:204-8. [PMID: 26755927 PMCID: PMC4707304 DOI: 10.4250/jcu.2015.23.4.204] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/06/2015] [Accepted: 12/07/2015] [Indexed: 12/25/2022] Open
Abstract
Coronary computed tomography angiography (CCTA) has high negative predictive power for detecting coronary artery disease. However CCTA is limited by moderate positive predictive power in the detection of myocardial ischemia. This is not unexpected because the diameter of a stenosis is a poor indicator of myocardial ischemia and discrepancy between the severity of stenosis and noninvasive tests is not uncommon. The value of stenosis for predicting future development of acute coronary syndrome represented by plaque rupture has been questioned. CCTA identifies the characteristics of high-risk plaque including positive remodeling, low density plaque and spotty or micro-calcification. Also, additional evaluation of myocardial ischemia using computational flow dynamics, and luminal attenuation gradient are expected to increase both diagnostic performance for hemodynamically significant stenosis and the predictive power for future cardiovascular risk. Technical advances in CCTA would enable evaluation of both coronary artery stenosis and myocardial ischemia simultaneously with high predictive performance, and would improve vastly the clinical value of CCTA.
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Affiliation(s)
- Hyung-Yoon Kim
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.; Department of Emergency Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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20
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Edvardsen T, Bucciarelli-Ducci C, Saraste A, Pierard LA, Knuuti J, Maurer G, Habib G, Lancellotti P. The year 2014 in the European Heart Journal - Cardiovascular Imaging. Part I. Eur Heart J Cardiovasc Imaging 2015; 16:712-8. [DOI: 10.1093/ehjci/jev150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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21
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McKavanagh P, Lusk L, Ball PA, Verghis RM, Agus AM, Trinick TR, Duly E, Walls GM, Stevenson M, James B, Hamilton A, Harbinson MT, Donnelly PM. A comparison of cardiac computerized tomography and exercise stress electrocardiogram test for the investigation of stable chest pain: the clinical results of the CAPP randomized prospective trial. Eur Heart J Cardiovasc Imaging 2014; 16:441-8. [DOI: 10.1093/ehjci/jeu284] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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22
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Almasi A, Pouraliakbar H, Sedghian A, Karimi MA, Firouzi A, Tehrai M. The value of coronary artery calcium score assessed by dual-source computed tomography coronary angiography for predicting presence and severity of coronary artery disease. Pol J Radiol 2014; 79:169-74. [PMID: 24995072 PMCID: PMC4079648 DOI: 10.12659/pjr.890809] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 04/30/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Measuring coronary artery calcium score (CACS) using a dual-source CT scanner is recognized as a major indicator for assessing coronary artery disease. The present study aimed to validate the clinical significance of CACS in predicting coronary artery stenosis and its severity. MATERIAL/METHODS This prospective study was conducted on 202 consecutive patients who underwent both conventional coronary angiography and dual-source (256-slice) computed tomography coronary angiography (CTA) for any reason in our cardiac imaging center from March to September 2013. CACS was measured by Agatston algorithm on non-enhanced CT. The severity of coronary artery disease was assessed by Gensini score on conventional angiography. RESULTS There was a significant relationship between the number of diseased coronary vessels and mean calcium score, i.e. the mean calcium score was 202.25±450.06 in normal coronary status, 427.50±607.24 in single-vessel disease, 590.03±511.34 in two-vessel disease, and 953.35±1023.45 in three-vessel disease (p<0.001). There was a positive association between calcium score and Gensini score (r=0.636, p<0.001). In a linear regression model, calcium score was a strong determinant of the severity of coronary artery disease. Calcium scoring had an acceptable value for discriminating coronary disease from normal condition with optimal cutoff point of 350, yielding a sensitivity and specificity of 83% and 70%, respectively. CONCLUSIONS Our study confirmed the strong relationship between the coronary artery calcium score and the presence and severity of stenosis in coronary arteries assessed by both the number of diseased coronary vessels and also by the Gnesini score.
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Affiliation(s)
- Alireza Almasi
- Department of Radiology, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Pouraliakbar
- Department of Radiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Sedghian
- Department of Radiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Karimi
- Department of Radiology, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ata Firouzi
- Department of Cardiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmood Tehrai
- Department of Radiology, Day General Hospital, Tehran, Iran
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